Life's New Beginnings - Supported Living



Main Training Employee
You will need Word Perfect 2000 or above for these forms. If you do not have that software, you can purchase it from WordPerfect Corel. For the APD files, you will need to go to the APD website and you will need Microsoft Word or Adobe Acrobat Reader to download the forms. If you do not have Microsoft Word, you can purchase that software from Microsoft. If you do not have Adobe Reader, you can download that software from http://www.adobe.com/reader. ALERT: Before you download any form, please exit and restart your browser to clear any old temporary forms from your computer memory or manually clear your Temporary Internet Files (cache). You MUST delete your Temporary Internet Files (clear the cache) to obtain the most current fomrs. If you do not make sure that your temporary internet files are deleted, you may not be able to download the newest and most current forms.
CLIENT FORMS
INTAKE FORMS To be completed on Intake of a new client.	Intake Release - authorizations giving permission to staff to assist the client with transportation and with medical, surgical procedure, dental care Information Acquisition/Release - to obtain client's permission to obtain or release information; only signed when needed Promotional-Training Release - to obtain client's permission for promotional or training purposes; only signed when needed Termination Letter - when a client is asked to leave the program Transitional Guide - when a client moves Transition Report - when a client leaves or enters the program Transition Report PRINT- complete by hand if not computer Supported Living Program Contract - contract between the client and/or guardian/representative to enter the supported living program Intake Interview -interview questions to determine if the client is interested in the program and to get to know the client IHSS Routine-Client specific routine Service Descriptions - provide to client and/or guardian on Intake SLC IHSS PCA Companion
GENERAL FORMS	Satisfaction Survey - Annual Demographics - Intake, Annual Disaster Preparedness - Intake, Annual - Every April Functional Community Assessment - Intake, Annual Health, Safety, & Housing Checklist - Intake, Annual, Quarterly Checklist - Intake, Annual, Quarterly - Use this to guide you through each Intake, Quarterly, and Annual Review MODIFIED 08-24-12; 10-03-12 Topics/Charts - Intake, Annual, Quarterly Must be used with Reference information MODIFIED 08-24-12 Status Check - Annual, Quarterly - for Non-SLP clients only Status Medical Update - Intake, Quarterly MODIFIED 08-24-12 Provider/Client Schedule - Annual or if there is a change Incident Report APD- Select Incident Reporting Form or Follow-Up Measures Taken See the Medication Error Report to report medication errors. Learning Experiences - Use 1x month with the Learning Experiences Instructions MODIFIED 08-24-12 Learning Experiences Instructions MODIFIED 08-24-12 Client-Guardian Release - Intake, Annual - to obtain permission to collect and use client information and to ensure client and guardian understand the services being provided Delmarva Review Questions - a reminder of areas staff should go over with each client Delmarva Service Specific Areas - areas to cover with the client
FINANCIAL	Individual Financial Profile - I, A, Q Individual Financial Profile Attachment - I, A, Q for clients who have IHSS and/or roommates Individual Financial Profile PRINT Individual Financial Profile Attachment PRINT Expense Log - to keep track of client expenses Individual Financial Profile - SAMPLE Individual Financial Profile Attachment - SAMPLE
IMPLEMENTATION PLAN	Implementation Plan Signature Page - used for all goals MODIFIED 08-24-12 Implmentation Plan Goal Action Plan - for each goal to specify the action plan MODIFIED 08-24-12 Transition Plan - use whenever you have not received the SP from the WSC NEW 08-24-12 Support Plan Update - to update the Support Plan prior to writing the IP
MEDICAL FORMS All clients must have the first three forms completed. Clients who require medications, must also have an Informed Consent for each medication assistant provider and a Medication Administration Book containing all appicable forms.	Health History - history of client's health Medication Administration Agreement - agreement between client and company Medication Administration Authorization APD - physician's authorization for client medication administration Informed Consent APD - to obtain client permission for each staff who assists with medicaiton administration Medication Notes - tracking of "other" medication information 3 Dose Tracking - to track possible side effects on ALL new medications Medical Exam Form - for the client to use when he does not want staff with him Medical Treatment Log - to track all health appointments New & Refill Medications - tracking for refilling medications PRN and OTC List - to obtain physician authorization for non-prescription medications Seizure Report - tracking of seizures Medication Administration Report (MAR) - or use the pharmacy generated MAR Medication Error Report (MER) APD - to report a medication error Medication Destruction Record APD - to track destruction of medications Controlled Substance Count APD - to track controlled medications Off-Site Medication Form APD - to track medications when the client is not home Advancd Directives/Living Will - Information & Forms Do Not Resuscitate Order (DNRO) - Information Do Not Resuscitate Order (DNRO) - Form NOTE: to be legally valid the DNRO form must be printed on yellow legal paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow legal paper.
REFERENCE Use these documents with the Topics/Charts. When the client/guardian signs the Topics/Charts during each Quarterly Review, he is agreeing that he understands each topic. The Functional Community Assessment is done during the Annual Review only.	Rights, Responsibilities, & Choice Rights, Responsibilties, & Choice Chart - chart to be posted/available in the client home Client Reporting Measures - how to report abuse, neglect, rights violations, etc Client Reporting Measures Chart - chart to be posted/available in the client home Due Process HIPAA Staffing Authorization - explains staffing Key Authorization - provides permission for specific staff to have a house key Financial Authorization - provides permission for client to have help with finances Functional Community Assessment Categories- areas used with the annual Functional Community Assessment Relationship Map-shows the client's circle of support Safety & Emergency Procedures- provides areas to cover for safety and emergencies Grievance Form - form used ONLY if the client or his advocate is submitting a grievance Abuse Topics - Annual form covering abuse, neglect, exploitation NEW 08-24-12
SUMMARY FORMS	Annual Summary - 3rd Quarter Summary Quarterly Summary - 1st, 2nd, and 4th Quarter Summary Person-Centered Planning - client planning for upcoming Support Plan; done for the 3rd Quarter, before the Support Plan meeting Annual Summary PRINT Quarterly Summary PRINT Person-Centered Planning PRINT Annual Summary - SAMPLE Quarterly Summary - SAMPLE Person-Centered Planning - SAMPLE
SERVICE LOGS	DO NOT USE THESE ON OR AFTER 01-01-2013 IHSS Service Log -Live-In IHSS Service Log For use on the computer IHSS Service Log PRINT For use if you do your log by hand IHSS Service Log Sample Use only to see an example of how to use the form All Other Services including hourly IHSS Service Log For use on the computer Service Log PRINT For use if you do your log by hand Service Log Sample Use only to see an example of how to use the form NEW SERVICE LOGS - IBUDGET If you are not using a computer to do your service logs, you need to re-consider using one. When the new IBudget Handbook is implemented, you will be required to submit your service logs on the computer. REMEMBER, do NOT change fonts on the service logs. USE VIEW-ZOOM while typing to enlarge what you see on the screen. Please contact me if you have problems or questions. (leslie) IBudget Service Log NEW 01-01-13 Service Log - to complete on the computer Service Log - to complete by hand Personal Supports-DAY, QTR (Formerly Known As: IHSS-Day, IHSS-QTR, PCA) Life Skills Development Level I (Formerly Known As: Companion) Supported Living Coach (Formerly Known As: SLC) INSTRUCTIONS SAMPLE IBudget Service Log - Supported Living Coach (SLC)
SELF-ASSESSMENT	Grievance Log - maintained by the program administrator Incident Log - maintained by the program administrator Staff Self-Assessment - completed 1 time a year Client Self-Assessment - completed 1 time a year; used with the Satisfaction Survey to determine trends Trends - QIP - completed by the program administrator